564 Heart 2000;83:564–569

PRACTICE OBSERVED Heart: first published as 10.1136/heart.83.5.564 on 1 May 2000. Downloaded from

The Newcastle protocols for head-up tilt table testing in the diagnosis of vasovagal , carotid sinus hypersensitivity, and related disorders

R A Kenny, D O’Shea, S W Parry

Head-up tilt table testing had been used as an Contraindications to head-up tilt table investigative tool in the pathophysiology of testing orthostatic stress for more than 50 years,1 Head-up tilt table testing is safe with few before the initial demonstration of its utility in reported adverse events.416While there are no the diagnosis of unexplained syncope.2 The reported deaths during tilt testing in the world Westminster group’s landmark study found literature, we are aware of some anecdotal that 67% of patients with otherwise unex- reports of fatal outcome during tilt testing, and plained syncope demonstrated a vasovagal caution should be applied as follows: relative reaction during head-up tilt, compared to only contraindications include clinically severe left 10% of healthy controls.2 Head-up tilt table ventricular outflow obstruction, critical mitral testing has since evolved into the diagnostic test stenosis, and patients in whom low organ per- of choice in vasovagal syncope and related dis- fusion pressures may compromise end artery orders, but there are still wide variations in the supplied tissue, as in severe proximal coronary protocols used in various centres, hampering artery and cerebrovascular stenosis. Where not only the clinical utility of the test but the such pathology is suspected, caution should be

adequate assessment of research activity in the exercised regarding the duration and degree of http://heart.bmj.com/ field. The following protocols are based on the allowed during tilt testing. Con- available evidence and our experience in this traindications to provoked tilt field and, as such, provide a practical and table testing are discussed in the appropriate standardised approach. They are intended for section. use by cardiologists and other physicians with an interest in this topic, and hence assume some prior knowledge of the procedure. A

more detailed description and justification for Head-up tilt table test methodology on September 29, 2021 by guest. Protected copyright. the protocols is readily available.34 The conditions under which the head-up tilt test are carried out critically influence out- come, hence these will be examined in detail.

Indications for head-up tilt table testing PATIENT PREPARATION Head-up tilt table testing should be considered Patients, in particular those over 60 years old, in patients with recurrent syncope or presyn- should be fasted for no more than two hours cope, or in high risk patients with a history of a before the procedure in order to avoid the con- single syncopal episode (for example, those founding eVects of relative dehydration and suVering serious injury during syncope or hypotension.417 The procedure should be those experiencing syncope while driving) explained to the patient who should rest supine where no other cause for symptoms is sug- for 20–45 minutes.18–20 A longer period is Cardiovascular gested by initial history, examination or cardio- particularly important if intravascular instru- Investigation Unit, 19 21 Victoria Wing, Royal vascular and neurological investigations. Tilt mentation is required. Where practicable, Victoria Infirmary, table testing may also be useful in the drugs aVecting the cardiovascular and auto- Queen Victoria Road, assessment of elderly patients with recurrent, nomic nervous systems and those likely to Newcastle upon Tyne unexplained falls.5 The head-up tilt table test aVect intravascular volume should be discon- NE1 4LP,UK may also have a role in the diVerential diagno- tinued for at least five half lives before the test17 R A Kenny sis of convulsive syncope,5–7 orthostatic unless they are implicated as an attributable D O’Shea 8 SWParry hypotension, the postural orthostatic tachy- cause of syncope, in which case testing should cardia syndrome,9 psychogenic10 and be done on medications. While in the head-up Correspondence to: hyperventilation11 12 syncope, and carotid sinus tilt position, the patient should be instructed to Professor Kenny hypersensitivity.13–15 The Newcastle protocol avoid movement of the lower limb musculature email: [email protected] for carotid sinus massage is detailed later in this and joints in order to maximise venous Accepted 7 January 2000 article. pooling.417 Head-up tilt table testing 565

mise stimuli aVecting autonomic nervous function, the test should occur in a quiet, dimly

lit room at a comfortable temperature. Ad- Heart: first published as 10.1136/heart.83.5.564 on 1 May 2000. Downloaded from vanced resuscitation equipment should be immediately available and to the standard required in exercise tolerance testing facilities.4 The test should be continuously supervised by a physician, nurse or technician experienced in the management of the test and its potential complications. If not directly supervised by such, a physician experienced in advanced car- diac life support should be immediately available at all times.

TILT TABLE ANGLE AND DURATION OF THE HEAD-UP TILT TABLE TEST Tilt table angle and the duration of the tilt test are crucial determinants of its positivity, sensi- 42324 Figure 1 Continuous digital photoplethysmography tivity, and specificity. Tilt angles of be- (Finapres, Ohmeda) tween 60° and 80° are optimal in provoking suYcient orthostatic stress without increasing 42024 EQUIPMENT, MONITORING, AND ENVIRONMENT the incidence of false positive results and The tilt table should be of the foot plate are recommended by most authorities.4524Our support type. Whether mechanically or electri- own practice utilises a 70° angle for head-up tilt cally powered, it should allow rapid achieve- table testing.19 25 ment of the upright posture and allow Duration of the drug free, passive tilt test has calibrated tilt angles of between 60° and 80°; been reported from 10–60 minutes by various rapid and smooth resumption of the supine centres.5 19 20 24–32 There are little hard data position should be easily achievable. Electro- available on the relative merits of diVerent drug cardiographic monitoring should occur con- free, passive tilt test periods, though most tinuously during symptoms or haemodynamic recent reports favour prolonged passive changes and every minute otherwise. head-up tilt (30–45 minutes).41920 Fitzpatrick pressure monitoring should be of the continu- and colleagues noted a significant increase in ous, non-invasive, beat-to-beat variety (for the number of false negative results with example, digital photoplethysmography, Fin- shorter tilt periods.20 The mean time to syncope in their patients was 24 minutes20; apres, Ohmeda, Wisconsin (fig 1), or Port- http://heart.bmj.com/ apres, TNO Biomedical, Amsterdam), since assuming a normal distribution plus two sphygmomanometric measures are insensitive standard deviations, a duration approaching 45 to rapid changes in . The newly minutes would be optimal at present,424 and published classification of the haemodynamics our own practice is to continue the tilt test for of vasovagal syncope by Brignole and 40 minutes or until symptoms supervene. colleagues,22 which has important implications for both clinical practice and research, is Newcastle protocols overview dependent on continuous and detailed blood The Newcastle protocols for head-up tilt pressure monitoring, making beat-to-beat as- testing in the diagnosis of vasovagal syncope on September 29, 2021 by guest. Protected copyright. sessment essential, though sphygmomanomet- are summarised in table 1. Patient preparation, ric measures continue to be used. The environment, and monitoring should proceed Portapres device has the added advantage of as described above. Termination of the test derived measures of stroke volume, cardiac should occur immediately positivity criteria are output, total peripheral resistance, etc, but is achieved, or if patient discomfort, significant unfortunately rather more costly, while Fin- or other adverse event develops. apres is no longer in production. Routine Blood pressure is recorded at one minute intra-arterial blood pressure monitoring is not intervals, with ECG recordings made at one advised. Blood pressure should similarly be minute intervals or continuously during symp- recorded continuously (or as frequently as is toms or haemodynamic derangements. Intra- practicable) during symptoms and at one venous cannulation is avoided in all but the minute intervals otherwise. In order to mini- isoprenaline protocols to preclude its adverse eVects on specificity.19 21 Table 1 Summary of Newcastle protocols for head-up tilt table testing DRUG FREE PASSIVE HEAD-UP TILT Tilt test description Method The patient is rested supine for 20 minutes Passive drug free tilt 40 min at 70° before the test, then tilted upright for 40 min- Isoproterenol (µg) tilt* 5 min tilt, 5 min supine 5 min 1 µg/min supine, 5 min 1 µg/min ° at 70° Infusion discontinued, supine 2 min 5 min 3 µg/min utes at an angle of 70 . supine, 5 min 3 µg/min at 70° GTN tilt 2 metred doses sublingual GTN spray supine 5 min supine PHARMACOLOGICAL PROVOCATION HEAD-UP TILT then 20 min at 70° TESTING *Based on Almquist et al.25 Isoprenaline head-up tilt test Patients should remain supine for 20 minutes before testing. Isoproterenol and GTN tilts should The patient remains supine for 20 minutes, follow non-diagnostic passive drug free tilt where history is suggestive of vasovagal syncope. Tilt ° should be terminated if symptom reproduction with concomitant hypotension/bradycardia or and is then tilted to 70 for five minutes. The adverse event develops. See text for further details. supine position is again assumed for five 566 Kenny, O’Shea, Parry

minutes’ re-equilibration. Isoprenaline is then Miscellaneous infused at a rate of 1 µg/min for five minutes Edrophonium,37 clomipramine,38 and adeno- 39–41 supine, then five minutes at 70° tilt. The infu- sine have all recently been reported as Heart: first published as 10.1136/heart.83.5.564 on 1 May 2000. Downloaded from sion is discontinued for two minutes during eVective provocative agents in the tilt table which the patient remains supine. Isoprenaline aided diagnosis of vasovagal syncope, but is then recommenced at 3 µg/min for five min- further assessment of these agents is required utes supine and five minutes at 70°. Higher before their more widespread adoption. doses of isoprenaline should not be used 23 33 34 because of adverse eVects on specificity. LOWER BODY NEGATIVE PRESSURE Contraindications include ischaemic heart dis- The patient should remain supine for 20 min- ease, uncontrolled hypertension, left ventricu- utes and then tilted at 70° for 20 minutes. If lar outflow obstruction, and significant aortic symptomatic hypotension/bradycardia does stenosis, while caution should be used in not supervene, lower body negative pressure patients with known dysrhythmias. The infu- using a suction chamber surrounding a stand- sion should be discontinued if heart rate ard tilt table should be applied at 20 mm Hg at exceeds 150 beats per minute (bpm), blood the 70° angle for 10 minutes (fig 2).42 Suction pressure exceeds 180/100 mm Hg or if ar- may be increased to 40 mm Hg for 10 minutes, rhythmia, chest pain, severe tremulousness, though this may increase the rate of false posi- vomiting or other intolerable side eVects tivity. supervene. Side eVects are particularly promi- nent in elderly subjects.35 In the face of a strong clinical history and an initial non-diagnostic Positivity criteria passive tilt, glyceryl trinitrate (GTN) tilt, which The head-up tilt table test is judged positive if is better tolerated and has equal specificity in syncopal or pre-syncopal symptoms this age group, should be used in reproducing are accompanied preference.25 35 the patient’s original symptoms by hypotension, bradycardia (relative or other- wise) or both. Heart rate and blood pressure Glyceryl trinitrate head-up tilt test changes in isolation should not prompt a diag- The patient is rested supine as above, and two nosis of vasovagal syncope. metred doses (400–800 µg) of sublingual GTN spray are administered. Two metred doses are given to ensure an eVective dose to counter the eVects of GTN’s linear pharmacokinetic pro- Head-up tilt table testing in paediatric file and variable absorption.36 The patient patients Children as young as 3 years have successfully remains supine for a further five minutes and is 43 ° 25 undergone tilt table testing. Indications, con-

then tilted to 70 for 20 minutes. Others have http://heart.bmj.com/ traindications, and methodology are essentially reported adequate positivity and specificity the same as in adults,44–47 with the proviso that with continuous 60° tilting for 45 minutes with isoprenaline dosage should not exceed 0.03 µg/ the administration of 400 µg nitroglycerin at 20 kg/min where it is indicated.43 Sensitivities and minutes if syncope had not occurred,26 though specificities for both drug free passive tilt and this is not currently our practice. isoprenaline provoked tilt are similar to those reported in adults,47 though to our knowledge there is not yet any data on the merits of GTN

provoked tilt testing in this population. on September 29, 2021 by guest. Protected copyright.

Head-up tilt table testing in the elderly Few studies have addressed the issue of tilt testing specifically in the elderly, but those reported to date suggest that there should be no diVerences in tilting methodology.19 25 48–50 The main diVerence in older subjects lies in the more variable presenting symptoms seen in this group. Elderly patients with vasovagal syncope frequently have sudden onset of syncope with little or no prodrome, hence tilt test positivity criteria need to be viewed in this light.49 50

Heart rate variability during head-up tilt table testing The role of heart rate variability in the analysis of autonomic function is well established, but its relevance in the assessment and prediction of the physiologic and pathophysiologic re- sponses to head-up tilt table testing is uncer- tain. Its utility as a research tool is evident, but its role in the diagnosis and management of the Figure 2 Lower body negative pressure chamber tilt testing vasovagal syndrome remains unclear. Head-up tilt table testing 567

Non-vasovagal syncope related diagnostic type), or both (mixed subtype) during carotid uses of the head-up tilt table sinus massage.14 Recurrent syncope caused by

DIFFERENTIAL DIAGNOSIS OF CONVULSIVE carotid sinus stimulation, producing > 3 sec- Heart: first published as 10.1136/heart.83.5.564 on 1 May 2000. Downloaded from SYNCOPE onds asystole in the absence of medication that Short lived tonic–clonic movements and myo- depresses the sinus node or atrioventricular clonic jerks are a not infrequent accompani- node conduction, is a class 1 indication (level ment of vasovagal syncope, particularly during C) for pacemaker implantation, while recur- prolonged asystole,5 and their presence may rent syncope without clear, provocative events prompt a misdiagnosis of epilepsy,56 often and with a hypersensitive cardioinhibitory labelled as refractory.7 Rapid recovery, the response, is a class IIa indication according to short duration of the episode, and the absence American College of Cardiology/American of postictal suggest a vas- Heart Association guidelines.51 Despite these ovagal diagnosis, which can only be made with criteria, there is still wide variation within the a high index of suspicion and appropriate tilt UK of implant rates for carotid sinus syn- testing, particularly with concurrent electro- drome, ranging from 25% of all systems encephalography.5–7 implanted in centres with an interest in this disorder, to 1–2% in other UK centres.52 In POSTURAL ORTHOSTATIC both the clinical and research arenas, stand- SYNDROME ardisation of carotid sinus massage (CSM), the Postural tachycardia in association with rela- sole currently practicable diagnostic test for tively mild hypotension has been recently carotid sinus hypersensitivity, is thus desirable. described and diagnosed with the aid of the head-up tilt position, and is thought to Indications for carotid sinus massage represent a mild form of autonomic dysfunc- CSM should be considered in older patients tion rather than a variant of vasovagal syncope.9 presenting with loss of consciousness, unex- The syndrome is diagnosed on the basis of a plained falls and presyncope, where history, heart rate increase of > 30 bpm (or a maxi- examination, and other cardiovascular and mum heart rate of 120 bpm) in the absence of neurological investigations have not been profound hypotension but reproducing clearly identified as an attributable cause for symptoms,9 which can include light headed- symptoms. ness, fatigue, presyncope, and dizziness. Contraindications to carotid sinus massage Orthostatic hypotension has traditionally been Myocardial infarction, transient ischaemic at- diagnosed on the basis of a fall in blood tack (TIA) or stroke in the three months before pressure during active standing. This definition attendance are absolute contraindications, as is http://heart.bmj.com/ was recently expanded by the American Auto- any previous adverse reaction to CSM. Previ- nomic Society and the American Academy of ous ventricular fibrillation (VF) or tachycardia Neurology to include a fall in systolic blood (VT) are relative contraindications. If carotid pressure of > 20 mm Hg or diastolic blood bruits are present, carotid Doppler ultrasonog- pressure of > 10 mm Hg using a tilt table in the raphy should precede CSM. We currently head-up position within three minutes and at avoid CSM in those with a > 70% stenosis and an angle of 60°.8 perform the test supine only in those with a 50–70% stenosis. The presence of a carotid PSYCHOGENIC AND HYPERVENTILATION SYNCOPE bruit is a poor indicator of the presence or on September 29, 2021 by guest. Protected copyright. Psychogenic syncope, or loss of consciousness severity of carotid artery stenosis,53 butinthe in the absence of heart rate, blood pressure, absence of prospective studies on the predictive electroencephalographic or transcranial Dop- value of carotid Doppler studies, our current pler abnormalities, has been reliably diagnosed practice reflects a safe and pragmatic approach using the head-up tilt table test.10 Clinical fea- to this test. tures include sudden and dramatic syncope, a prolonged recovery period, and disorientation Carotid sinus massage methodology after the episode, all features rarely seen in vas- CSM should only be performed by a clinician ovagal attacks.10 Hyperventilation syncope is skilled in the management of its potential com- considered under the same rubric of psychiat- plications. Following a detailed history, clinical ric disorder,11 with diagnosis established by the examination (including carotid auscultation), demonstration of hyocapnia (which is thought and explanation of the procedure, the patient to stimulate cerebral vasoconstriction) and should lie supine for a minimum of 5 minutes alkalosis during head-up tilt table testing.11 12 with surface ECG and blood pressure monitor- Traditionally, arterial blood gas measurement ing on a footplate type tilt table. (Where possi- has provided the gold standard for these values, ble, phasic non-invasive beat to beat blood but a recent study reported on the use of end pressure monitoring (for example, Finapres) is

tidal PCO2 as the marker of hyperventilation to be preferred since the blood pressure nadir (“capnography tilt test”).11 occurs at around 18 seconds, returning to base- line at 30 seconds. Conventional automated Carotid sinus hypersensitivity systems will thus be insuYciently sensitive to The diagnosis of carotid sinus hypersensitivity track this rapid response. This is of most rests on the finding of > 3 seconds asystole importance where the vasodepressor response (cardioinhibitory subtype), > 50 mm Hg fall in is of particular interest. Firm, longitudinal systolic blood pressure (vasodepressor sub- massage should then be performed for 568 Kenny, O’Shea, Parry

1 CSM START CSM STOP test for vasovagal syncope, and the Newcastle protocols provide guidance not only on passive

and provocative tilt testing, but also on Heart: first published as 10.1136/heart.83.5.564 on 1 May 2000. Downloaded from 118/59 mmHg 64/36 mmHg diagnostic uses of the test outwith the realm of (at 18 sec) vasovagal syncope. These protocols, based on current evidence and our experience in this 5.4 s field, are an attempt to provide comprehensive guidance on tilt testing and carotid sinus mas- sage, which will be of interest not only to those setting up new units, but also to those with Figure 3 Mixed carotid sinus hypersensitivity existing similar facilities. 5 seconds over the site of maximal pulsation of 54 the right carotid sinus, which is located 1 Hellebrandt FA, Franseen EB. Physiologic study of vertical between the superior border of the thyroid car- stance in man. Physiol Rev 1943;23:220–5. 2 Kenny RA, Ingram A, Bayliss J, et al. Head-up tilt: a useful tilage and the angle of the mandible. Some test for investigating unexplained syncope. Lancet 1986;i: authors recommend continuing CSM for 10 1352–4. 55 3 Parry SW, Kenny RA. Tilt table testing. In: Malik M, ed. seconds if there is no asystole after 5 seconds, Clinical guide to cardiac autonomic tests. Amsterdam: Kluwer but this is not our practice. Simple light Academic Publishers, 1998:67–99. 4 Benditt DG, Ferguson DW, Grubb BP, et al. Tilt table test- pressure over the carotid sinus will not reliably ing for assessing syncope. ACC expert consensus docu- produce a hypersensitive response. ment. J Am Coll Cardiol 1996;28:263–75. 5 Grubb BP, Samoil D. Neurocardiogenic syncope. In: Kenny CSM is performed initially on the right side RA, ed. Syncope in the older patient: causes, investigations and when supine, as up to 66% of subjects with consequences of syncope and falls. London: Chapman & Hall, 1996:1–106. carotid sinus hypersensitivity have a positive 6 Grubb BP, Ferard G, Roush K, et al.DiVerentiation of con- response on the right side,56 potentially avoid- vulsive syncope and epilepsy with head-up tilt table testing. Ann Intern Med 1991;115:871–6. ing the need for repeated CSM. Massage 7 Zaidi A, Clough P, Scheepers B, Fitzpatrick A. Treatment should be discontinued if asystole > 3 seconds resistant epilepsy or convulsive syncope. BMJ 1998;317: 869–70. occurs (fig 3), while prolonged asystole should 8 Consensus Committee of the American Autonomic Society result in prompt frappe. Symptoms, including and the American Academy of Neurology. Consensus symptom reproduction, blood pressure, and statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. J R-R interval should be recorded. If right sided Neurol Sci 1996;144:218–19. 9 Grubb BP, Kosinski DJ, Boehm K, et al. The postural massage is non-diagnostic, the procedure orthostatic tachycardia syndrome. A neurocardiogenic should be repeated, consecutively, in the left variant identified during head-up tilt table testing. PACE ° 1997;20(I):2205–12. supine position, and the right and left 70 10 Petersen MEV, Williams TR, Sutton R. Psychogenic head-up tilt position, following haemodynamic syncope diagnosed by prolonged head-up tilt testing. QJ re-equilibration in all cases. In up to 30% of Med 1995;88:209–13. 11 Naschitz JE, Gaitini L, Mazov L, et al. The capnography-tilt subjects the response cannot be elicited in the test for the diagnosis of hyperventilation syncope. QJMed http://heart.bmj.com/ supine position and is only present during 1997;90:139–45. 13–15 57 12 Roberston DA, Taylor R. Metabolic and endocrine causes of massage in the head upright tilt position. syncope. In: Kenny RA, ed. Syncope in the older patient: At the end of the procedure the patient should causes, investigations and consequences of syncope and falls. London: Chapman & Hall, 1996:240–65. remain supine for at least 10 minutes, which in 13 Hammill SC, Holmes DR, Wood DL. Electrophysiologic our experience has reduced neurological com- testing in the upright position: improved evaluation of patients with rhythm disturbance using a tilt table. JAm plication rates. Coll Cardiol 1984;4:65–71. 14 Kenny RA, McIntosh SJ. Carotid sinus syndrome. In: Kenny RA, ed. Syncope in the older patient: causes,

Complications of carotid sinus massage investigations and consequences of syncope and falls. London: on September 29, 2021 by guest. Protected copyright. 58 59 Chapman & Hall, 1996:107–22 Stroke and TIA following CSM are rare. 15 McIntosh SJ, Lawson J, Kenny RA. Clinical characteristics Where neurological signs ensue, the procedure of vasodepressor, cardioinhibitory and mixed carotid sinus syndrome in the elderly. Am J Med 1993;95:203–8. should be abandoned, the patient placed in the 16 Gatzoulis KA, Mamarelis IE, Apostolopoulos T, et al. Poly- supine position, and measures taken to ensure morphic ventricular tachycardia induced during tilt table testing in a patient with syncope and probable dysfunction that the blood pressure is returned rapidly to of the sinus node. PACE 1995;18(II):1075–9. normotensive levels. Consideration should be 17 Victor J. Tilt test: environment, material, patient prepara- tion. In: Blanc JJ, Benditt D, Sutton R, eds. Neurally medi- given to the administration of aspirin 300 mg if ated syncope: pathophysiology, investigations, and treatment. not contraindicated. Stroke should be man- The Bakken Research Center Series Vol 10. Armonk, New York: Futura, 1996:77–8. aged as per local guidelines. Cardiac complica- 18 Kapoor WN, Smith MA, Miller NL. Upright tilt testing in tions, including ventricular60 61 and atrial evaluating syncope: a comprehensive literature review. Am 62 JMed1994;97:78–88. have been reported rarely. In 19 McIntosh SJ, Lawson J, Kenny RA. Intravenous cannulation more than 16 000 episodes of CSM we have alters the specificity of head-up tilt testing for vasovagal 58 59 syncope in elderly patients. Age Ageing 1994;23:317–19. never encountered VT or VF, though 20 Fitzpatrick AP, Theodorakis G, Vardas P, et al. Methodology advanced resuscitation facilities should be of head upright tilt table testing in patients with unexplained syncope. J Am Coll Cardiol 1991;17:125–30. immediately to hand. 21 Stevens PM. Cardiovascular dynamics during orthostasis and the influence of intravascular instrumentation. Am J Cardiol 1966;17:211–18. Conclusion 22 Brignole M, Menozzi C, Del Rosso A, et al.New classification of haemodynamics of vasovagal syncope: Neurocardiovascular disorders, including the beyond the VASIS classification. Analysis of the pre- vasovagal syndrome and carotid sinus hyper- syncopal phase of the tilt test without and with nitroglyc- erin challenge. Europace In press. sensitivity, are some of the most common 23 Kapoor WN, Brant N. Evaluation of syncope by upright tilt causes of syncope, but clinical diagnosis and testing with isoproterenol. A non-specific test. Ann Intern Med 1992;116:358–63. research activity are hampered by the diversity 24 Mansourati J, Blanc JJ. Tilt test procedure: angle, duration of diagnostic protocols used in diVerent and positivity criteria. In: Blanc JJ, Benditt D, Sutton R, centres. Tilt table testing has developed eds. Neurally mediated syncope: pathophysiology, investigations, and treatment. The Bakken Research Center Series Vol 10. considerably since its inception as a diagnostic Armonk, New York: Futura, 1996:79–83. Head-up tilt table testing 569

25 McIntosh S, Lawson J, da Costa D, et al. Use of sublingual 44 Thilenius OG, Quinones JA, Huusayni TS, et al. Tilt test for glyceryl trinitrate during head-up tilt as a provocative test diagnosis of unexplained syncope in paediatric patients. for vasovagal responses in elderly patients with unexplained Pediatrics 1991;87:334–8. syncope. Cardiology in the Elderly 1996;4:33–7. 45 Lerman-Sagie T, Rechavia E, Strasberg B, et al. Head-up tilt Heart: first published as 10.1136/heart.83.5.564 on 1 May 2000. Downloaded from 26 Del Rosso A, Bartoli P, Bartoletti A, et al. Shortened for the evaluation of syncope of unknown origin in head-up tilt testing potentiated with sublingual nitroglyc- children. J Pediatr 1991;118:676–9. erin in patients with unexplained syncope. Am Heart J 1998;135:564–70. 46 Strieper JM, Auld DO, Hulse E, et al. Evaluation of 27 Almquist A, Goldenberg IF, Milstein S, et al. Provocation of recurrent pediatric syncope: role of tilt table testing. Pediat- bradycardia and hypotension by isoproterenol and upright rics 1994;93:660–2. posture in patients with unexplained syncope. N Engl J 47 Alehan D, Lenk M, Ozme S, et al. Comparison of sensitivity Med 1989;320:346–51. and specificity of tilt protocols with and without isoproter- 28 Natale A, Akhtar M, Jazayeri M, et al. Provocation of hypo- enol in children with unexplained syncope. PACE 1997;20: tension during head-up tilt testing in subjects with no his- 1769–76. tory of syncope or presyncope. Circulation 1995;92:54–8. 48 Grubb BP, Wolfe D, Samoil D, et al. Recurrent unexplained 29 Sheldon R, Killam S. Methodology of isoproterenol-tilt syncope in the elderly: the use of head-upright tilt table table testing in patients with syncope. J Am Coll Cardiol testing in evaluation and management. J Am Geriatr Soc 1992; :773–9. 19 1992;40:1123–8. 30 Blanc J, Victor J, Mansourati J, et al. Accuracy and mean duration of diVerent protocols of head-up tilt testing. Am J 49 Sutton R. Vasovagal syncope: clinical features, epidemiology Cardiol 1996;77:310–13. and natural history. In: Blanc JJ, Benditt D, Sutton R, eds. 31 Raviele A, Gasparini G, Di Pede F, et al. Nitroglycerine Neurally mediated syncope: pathophysiology, investigations, and infusion during upright tilt: a new test for the diagnosis of treatment. The Bakken Research Center Series Vol 10. vasovagal syncope. Am Heart J 1994;127:103–11. Armonk, New York: Futura, 1996:71–6. 32 Fitzpatrick A, Sutton R. Tilting towards a diagnosis in 50 Bloomfield D, Maurer M, Bigger JT. EVects of age on out- recurrent unexplained syncope. Lancet 1989;i:658–770. come of tilt-table testing. Am J Cardiol 1999;83:1055–8. 33 Carlioz R, Graux P, Haye J, et al. Prospective evaluation of 51 Gregoratos G, Cheitlin MD, Conill A, et al. ACC/AHA high dose and low dose isoproterenol upright tilt protocol guidelines for implantation of cardiac pacemakers and for unexplained syncope in young adults. Am Heart J 1997; antiarrhythmia devices. JACC 1998;31:1175–209. :346–52. 133 52 Dey AB, Bexton RS, Tynan MM, et al. The impact of a 34 Fitzpatrick AP, Lee RJ, Epstein LM, et al.EVect of patient characteristics on the yield of prolonged baseline head-up dedicated “Syncope and Falls” service on pacing practice tilt testing and the additional yield of drug provocation. in Northeastern England. PACE 1997;20(pt II):815–7. Heart 1996;76:406–11. 53 Hankey GJ, Warlow CP. Symptomatic carotid ischaemic 35 Graham LA, Gray JC, Kenny RA. Comparison of provoca- events: safest and most cost eVective way of selecting tive tests for unexplained syncope: isoprenaline and patients for angiography, before carotid endarterectomy. glyceryl trinitrate diagnosing vasovagal syncope. Eur Heart BMJ 1990;300:1485–91. J In press. 54 Morley CA, Sutton R. Carotid sinus syncope. Int J Cardiol 36 Nakashima E, Rigod JF, Lin ET, et al. Pharmacokinetics of 1984;4:287–93. nitroglycerin and its dinitrate metabolites over a thirtyfold 55 Brignole M, Menozzi C, Gianfranchi L, et al. Neurally range of oral doses. Clin Pharmacol Ther 1990;47:592–8. mediated syncope detected by carotid sinus massage and 37 Lurie KG, Dutton J, Mangat R, et al. Evaluation of head up tilt in sick sinus syndrome. Am J Cardiol 1991;68: edrophonium as a provocative agent for vasovagal syncope 1032–6. during head-up tilt table testing. Am J Cardiol 1993;72: 56 Thomas JE. Hyperactive carotid sinus reflex and carotid 1286–90. sinus syncope. 1969; : 127–39. 38 Flevari P, Theodorakis GN, Zarvaliss E, et al. Head-up tilt Mayo Clin Proc 44 test after clomipramine challenge in neurally mediated syn- 57 Parry SW, Richardson DA, O’Shea D, et al. Diagnosis of cope patients [abstract]. PACE 1998;21(4 part II):793, carotid sinus hypersensitivity in older adults: carotid sinus A13. massage in the upright position is essential. Heart 2000;83: 39 Shen W-K, Hammill SC, Munger TM, et al. Adenosine: 22–3. potential modulator for vasovagal syncope. J Am Coll Car- 58 Davies AJ, Kenny RA. Incidence of complications after diol 1996;28:146–54. carotid sinus massage in older patients with syncope. Am J 40 Mittal S, Rohatgi S, Stein KM, et al. Can adenosine tilt test- Cardiol 1998;81:1256–7.

ing replace conventional tilt testing? J Am Coll Cardiol 59 Munro NC, McIntosh S, Lawson J, et al. Incidence of com- http://heart.bmj.com/ 1998;31(suppl):A1017–167. plications after carotid sinus massage in older patients with 41 Perez-Paredes M, Pico Aracil F, Sanchez Villanueva JG, et syncope. J Am Geriatr Soc 1994;42:1248–51. al. Role of adenosine triphosphate (ATP) in head-up 60 Matthews OA. Ventricular tachycardia induced by carotid tilt-induced syncope. 1998; Revista Espanola de Cardiologia sinus stimulation. 51:129–35. Journal of the Maine Medical Association 42 Hainsworth R, El-Bedawi KM. Orthostatic tolerance in 1969;60:135–6. patients with unexplained syncope. Clin Auton Res 1994;4: 61 Alexander S, Ping WC. Fatal ventricular fibrillation during 239–44. carotid sinus stimulation. Am J Cardiol 1966;18:289–91. 43 Grubb BP, Orecchio E, Kurczynski TW. Head-upright tilt 62 Blumenfeld S, SchaeVeler KT, Zullo RJ. An unusual table testing in evaluation of recurrent unexplained response to carotid sinus pressure. Am Heart J 1950;40: syncope. Paediatr Neurol 1992;8:423–7. 319–22. on September 29, 2021 by guest. Protected copyright.